Why is it So Difficult to Fund Prevention?

Mar 5, 2018

A West Virginia prevention program targeted at high risk diabetes patients is showing almost immediate results for participants such as Selena Hanshaw, a working mom of four kids ages 6 to 20.

“As a mother of four, I know for myself, you just kind of forget about yourself. You’re just so worried about care for everyone else, you kind of neglect yourself,” said Hanshaw. “I just didn’t want to accept the fact that I had diabetes. I wanted to pretend that it didn’t exist.”

Hanshaw is a nurse who was struggling to manage her diabetes. So she joined a local chronic care management program. The program is piloted by Marshall University School of Medicine in partnership with community health centers.

“We’re working specifically with high risk diabetes patients because of the cost that they represent to the health care system,” said Professor Richard Crespo who heads up the program. In this program, high risk diabetes patients are referred to a team, which includes a mid-level provider, such as a nurse-practitioner or physician’s assistant, a nurse and community health worker. The community health worker is someone from he community they serve.

Community health workers Samantha Runyon (left) and Kelli Browning (right) dress a diabetic patient's foot and talk about medication during a home visit.
Credit Kara Ardron

“What the community health workers do in our model is work with patients on things that they should be doing for themselves, but because of a variety of circumstances are not able to,” said Crespo.

At her home, Hanshaw meets with her community health worker Kelly Browning. As part of her diabetes management, Hanshaw is trying to lose weight.

“What do you think this week you can do?” asked Browning.

“Realistically, if it’s pretty, I would like to walk," Hanshaw answered.

“But if it’s not pretty what are you going to do?" Browning asked.

After weighing Hanshaw and going over her blood sugar, Browning works with her to develop a plan for the week.

“Each patient is completely different,” said Browning. “They all need something different from us. Some need that stability of ‘hey I’m going to call you every day and see that you took your medicine'. Whatever it is they need from us is what we do.”

Browning has 32 patients and is one of three community health workers serving Mingo County. The program started in 2011 and is now in three states employing more than 20 community health workers.

Crespo said that over the course of the program they’ve seen a clinically significant drop in blood sugar levels for participants.

“The more the blood sugar is controlled in the body, then [there is] less risk of amputation and heart disease,” he explained. “But more significantly is the decrease in using the emergency department and going to the hospital, and that’s the payoff is to the insurance companies-- the decrease in using those resources.”

The chronic care management program grant is funded from about seven different sources, according to Crespo. But grants aren’t a long-term fix. Crespo said he's been talking with West Virginia’s three private insurers and West Virginia Medicaid to continue funding the initiative.

“Conceptually it makes sense,” he said. “It’s just the way that funding and reimbursement happens in medical care in the United States is based on fee[s] for service, and this doesn’t fit that model. This is part of the dissonance, is figuring out a way to make it happen in how healthcare is paid for in the United States."

It’s not just changing the way insurance companies fund health care, but also the way the legislature does.

“What worries me is that we keep cutting these programs in order to balance the budget,” said Senator Ron Stollings, an internal medicine doctor from Boone County. Stollings said the state legislature is zeroing out a variety of state prevention programs. For him, prevention needs more funding, not less, with a focus on obesity, since the condition is related so heavily to not only type 2 diabetes, but high blood pressure and heart disease among other things.

“I think people up here who do the budgeting needs to understand that it’s a $2.4 billion problem to West Virginia, and to really focus on school-based programs,” he said. 

Prevention dollars are being redirected to opioid abuse prevention, but chronic diseases such as obesity, cancer and diabetes kill far more people and are far more expensive.

For Crespo, not all prevention dollars are the same. The work that they’re doing with the chronic disease management program is directly interrupting the cycle of expensive patients misusing the health care system. He said while “primary” prevention programs such as trying to prevent obesity and diabetes from happening in the first place, are important, it takes a longer time to see financial savings.

“The interesting thing about this project is that the savings are almost immediate when we are working with high risk patients, whereas in typical public health work, vaccinations and healthy eating, the benefit is there. But the benefits are going to happen 20-30 years down the road,” he said. “With this, the benefit happens at 5:00 today as far as the insurance companies are concerned."

It costs about $250 to participate in the program. Before being referred, some patients might be hospitalized two-four times a year or more. The American Diabetes Association estimates that diabetes costs the state $1.9 billion in 2012, with another $627 million lost due to productivity. 15 percent of West Virginians have diabetes, ranking the state number one in the country.

But Crespo said what truly makes the program successful is the human relationships that community health workers build with their patients. Haynard is a nurse. She knows what diabetes does and how to care for it. But without Browning’s encouragement she wasn’t doing what she was supposed to. It’s the accountability, she said, that helps her stay on track.


Appalachia Health News is a project of West Virginia Public Broadcasting, with support from the Marshall Health, Charleston Area Medical Center and WVU Medicine.